DSM-5 is here: Are psychiatrists ready to stop arguing about it?

The DSM-5 is released at the annual meeting of the American Psychiatric Assn. The so-called bible of psychiatry has been a matter of heated debate among mental health professionals.
(AP Photo / American Psychiatric Assn.)

Finally. After many contentious years, the American Psychiatric Assn. has unleashed DSM-5, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

If you know one thing about the DSM, it’s probably that this book is considered “the bible of psychiatry.” According to the APA, it “contains a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. health care system.” Psychiatrists rely on it, as do other doctors, psychologists, nurses, social workers, folks at insurance companies who figure out which conditions are covered, and many others.

DSM-5 represents the first comprehensive update to the manual since 1994. In the years leading up to its release this during the APA’s annual meeting in San Francisco, psychiatrists hotly debated the merits of adding new disorders to the list (Hoarding? Complicated Grief? Binge-Eating Disorder?) as well as proposals to amend or remove certain conditions that are already in the book. Underlying everything was this overarching consideration: “How to distinguish a mental illness from the rainbow of normal human behavior,” as Shari Roan put it in this 2011 Los Angeles Times story.

Over and over again, the answer to this question has been hashed out by the psychiatric community. The new DSM represents the consensus opinion, but that consensus is hardly unanimous. These being psychiatrists, they’ve had a lot to say throughout the process, and it hasn’t all been pretty. And – in the name of transparency – much of it has been in full view of the public.

One of the most vocal critics of DSM-5 is Dr. Allen Frances, who led the task force that developed its predecessor, DSM-IV. (Among the many changes this time around is a switch from Roman numerals to Arabic numerals.) In a 2010 Opinion piece in the Los Angeles Times, Frances derided the new book for seeking to turn too many examples of “normal” behavior into diagnosable conditions. In explaining why this was dangerous, he cited mistakes made by his own task force:

“Our panel tried hard to be conservative and careful but inadvertently contributed to three false ‘epidemics’ — attention-deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many "patients" who might have been far better off never entering the mental health system.”

Other detractors, led by Jack Carney, a licensed clinical social worker in Brooklyn, are calling for a boycott of the new manual. In an online petition, they urge those in the mental health field to neither buy nor use DSM-5 on the grounds that it “unsafe and scientifically unsound” and will cause millions of people to be incorrectly labeled as mentally ill, setting them up to be unnecessarily medicated. As of this writing, 1,917 people have signed the petition.

The Los Angeles Times has been covering these controversies since as least as far back as 2008. Here are some of the highlights:

Psychiatrists rewriting the mental health bible: Some psychiatrists warn that the tome runs the risk of medicalizing the normal range of human behaviors; others vehemently argue that it must be broad enough to guide treatment of those who need it. But all agree that the so-called bible of psychiatry is expected to be considerably more nuanced and science-based than the last edition, DSM-IV, published in 1994.

It’s a problem. But a disorder? Is compulsive shopping a biologically driven disease of the brain, a learned habit run amok, an addiction in its own right, or a symptom of the other dysfunctions — most notably depression — that so often accompany it? Where is the line between avid shopping (a norm widely observed in the United States) and compulsive shopping? And how, if this is an illness, is it best treated?

Is binge eating a psychiatric disorder? In light of new research and a seemingly growing population of patients who fit the broad description of binge eaters, psychiatrists must decide whether "binge-eating disorder" should stand alongside anorexia nervosa and bulimia nervosa as a separate psychiatric condition — identifiable by a distinct set of symptoms, a recognizable pattern of progression and a track record of response to certain treatments.

Sex addiction divides mental health experts: "There is no doubt in my mind that this condition exists and that it's serious," said Dr. Martin P. Kafka, an associate clinical professor of psychiatry at Harvard University who was a member of the DSM-5 work group on sexual disorders. "There are definitely men who are consumed by porn or consumed by sex with consenting adults — who have multiple affairs or multiple prostitutes. The consequences associated with this behavior are very significant, including divorce, pregnancy" and sexually transmitted disease, he said.

Child mental disorders: New diagnosis or another dilemma? "Everyone wishes we could have a genetic test or a blood test" to determine which disorder a child has, said Erik Parens, senior research scholar at the Hastings Center, a bioethics think tank in Garrison, N.Y. "Unfortunately, nature doesn't work the way we wish."

These stories offer a flavor of the debate. Now that DSM-5 has been officially published, are psychiatrists going to stop arguing about it? That seems unlikely.